Providing optimal care in the neonatal care units in India: How Covid-19 exacerbated existing barriers

Nearly one quarter (600,000) of all neonatal deaths worldwide per year occur in India. To reduce neonatal mortality, the Indian Ministry of Health and Family Welfare established neonatal care units, including neonatal intensive care units and specialized neonatal care units to provide immediate care at birth, resuscitation for asphyxiation, postnatal care, follow up for high-risk newborns, immunization, and referral for additional or complex healthcare services. Despite these efforts, neonatal mortality remains high, and measures taken to reduce mortality have been severely challenged by multiple problems caused by the Covid-19 pandemic. In this qualitative study, we conducted seven focus group discussions with newborn care unit nurses and pediatric residents and 35 key informant interviews with pediatricians, residents, nurses, annual equipment maintenance contractors, equipment manufacturers, and Ministry personnel in the Vidarbha region of Maharashtra between December 2019 and November 2020. The goal of the study was to understand barriers and facilitators to providing optimal care to neonates, including the challenges imposed by the Covid-19 pandemic. Covid-19 exacerbated existing barriers to providing optimal care to neonates in these newborn care units. As a result of Covid-19, we found the units were even more short-staffed than usual, with trained pediatric nurses and essential equipment diverted from newborn care to attend to patients with Covid-19. Regular training of neonatal nursing staff was also disrupted due to Covid-19, leaving many staff without the skills to provide optimate care to neonates. Infection control was also exacerbated by Covid-19. This study highlights the barriers to providing optimal care for neonates were made even more challenging during Covid-19 because of the diversion of critically important neonatal equipment and staff trained to use that equipment to Covid-19 wards. The barriers at the individual, facility, and systems levels will remain challenging as the Covid-19 pandemic continues.

Use of Artificial Intelligence for Digital Breast Tomosynthesis Screening: A Preliminary Real-world Experience

OBJECTIVE

The purpose of this study is to assess the "real-world" impact of an artificial intelligence (AI) tool designed to detect breast cancer in digital breast tomosynthesis (DBT) screening exams following 12 months of utilization in a subspecialized academic breast center.

METHODS

Following IRB approval, mammography audit reports, as specified in the BI-RADS atlas, were retrospectively generated for five radiologists reading at three locations during a 12-month time frame. One location had the AI tool (iCAD ProFound AI v2.0), and the other two locations did not. The co-primary endpoints were cancer detection rate (CDR) and abnormal interpretation rate (AIR). Secondary endpoints included positive predictive values (PPVs) for cancer among screenings with abnormal interpretations (PPV1) and for biopsies performed (PPV3). Odds ratios (OR) with two-sided 95% confidence intervals (CIs) summarized the impact of AI across radiologists using generalized estimating equations.

RESULTS

Nonsignificant differences were observed in CDR, AIR, and PPVs. The CDR was 7.3 with AI and 5.9 without AI (OR 1.3, 95% CI: 0.9-1.7). The AIR was 11.7% with AI and 11.8% without AI (OR 1.0, 95% CI: 0.8-1.3). The PPV1 was 6.2% with AI and 5.0% without AI (OR 1.3, 95% CI: 0.97-1.7). The PPV3 was 33.3% with AI and 32.0% without AI (OR 1.1, 95% CI: 0.8-1.5).

CONCLUSION

Although we are unable to show statistically significant changes in CDR and AIR outcomes in the two groups, the results are consistent with prior reader studies. There is a nonsignificant trend toward improvement in CDR with AI, without significant increases in AIR.

Abstract P022: Quantitative measures of breast density and breast cancer risk prediction among black women in a screening population

Background: Although mammographic density (MD) is a strong predictor of invasive breast cancer, it has been shown to increase the discriminatory ability of existing risk prediction models only slightly. Breast density is assessed visually by radiologists according to the Breast Imaging Reporting and Data System (BI-RADS) criteria, which has been shown to lack reproducibility. Additionally, the racial diversity of women included in the previous studies was limited. Quantitative measures of breast density have been developed that automatically measure density directly from images. Our prior work found that Black women had lower BI-RADS breast density, despite having a greater quantity of dense breast tissue on average compared with white women when quantitative measures were used. The study purpose was to determine if adding quantitative breast density measures improved breast cancer risk prediction for both white and Black women compared to the Breast Cancer Risk Assessment Tool (BCRAT). Methods: A total of 16,942 women (N=6881 white, N=10061 Black) screened with full-field digital mammography (FFDM) or with a combination of FFDM and digital breast tomosynthesis (DBT) at the Hospital of the University of Pennsylvania (HUP) between September 1, 2010 to December 31, 2014 were included. Area breast density measurements including dense area and area percent density were obtained using a fully automated, validated LIBRA software. All patients were followed from the date of first screening mammogram visit until breast cancer diagnosis or end of follow up on December 31, 2019. We used the BCRA R package (v2.1) for the BCRAT (https://dceg.cancer.gov/tools/risk-assessment/bcra) to estimate the expected 5 year absolute risk for breast cancer. We evaluated the area under the curve (AUC) and calibration (observed to expected ratio, O/E) of the following models: BCRAT alone, BCRAT + BI-RADS density, BCRAT + quantitative density measures, and BCRAT + BI-RADS density + quantitative density measures. Results: There were 123 breast cancers among white and 123 breast cancers among Black women. Adding dense area and area percent density to the BCRAT alone or BCRAT plus BI-RADS density did not improve predictive accuracy for white or Black women. AUC remained close to 0.59 for white women and 0.61 for Black women in all models, with no statistically significant differences in AUCs (DeLong Test p value = 0.09). Underprediction was worse in white women than in Black women. Under-prediction of the BCRAT was reduced when adding percent density from [O/E 1.24 vs. O/E 1.17] in white women. Calibration stayed relatively the same (O/E=1.10) for Black women even when adding both quantitative MD measures. Conclusion: Our results suggest that adding quantitative area mammographic density measurements to the BCRAT does not improves breast cancer risk prediction among Black or white women. Given the increasing use of digital breast tomosynthesis (DBT), future studies should examine whether volumetric breast density measures have superior predictive value among Black women.

Citation Format: Mattia A. Mahmoud, Anne Marie McCarthy, Despina Kontos, Emily Conant, Jinbo Chen, Sarah Ehsan, Lauren Pantalone, Walter Mankowski. Quantitative measures of breast density and breast cancer risk prediction among black women in a screening population. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P022.

Poor power quality is a major barrier to providing optimal care in special neonatal care units (SNCU) in Central India

Background: Approximately 25% of all neonatal deaths worldwide occur in India. The Indian Government has established Special Neonatal Care Units (SNCUs) in district and sub-district level hospitals to reduce neonatal mortality, but mortality rates have stagnated. Reasons include lack of personnel and training and sub-optimal quality of care. The role of medical equipment is critical for the care of babies, but its role in improving neonatal outcomes has not been well studied.  Methods: In a qualitative study, we conducted seven focus group discussions with SNCU nurses and pediatric residents and thirty-five key informant interviews and with pediatricians, residents, nurses, annual equipment maintenance contractors, equipment manufacturers, and Ministry of Health personnel in Maharashtra between December 2019 and November 2020. The goal of the study was to understand challenges to SNCU care. In this paper, we focus on current gaps and future needs for SNCU equipment, quality of the power supply, and use of SNCU equipment. Results: Respondents described a range of issues but highlighted poor power quality as an important cause of equipment malfunction. Other concerns were lack of timely repair that resulted in needed equipment being unavailable for neonatal care. Participants recommended procuring uninterrupted power supply (UPS) to protect equipment, improving quality/durability of equipment to withstand constant use, ensuring regular proactive maintenance for SNCU equipment, and conducting local power audits to discern and address the causes of power fluctuations. Conclusions: Poor power quality and its negative impact on equipment function are major unaddressed concerns of those responsible for the care and safety of babies in SNCUs in Central India. Further research on the power supply and protection of neonatal equipment is needed to determine a cost-effective way to improve access to supportive care in SNCUs and desired improvements in neonatal mortality rates.

Outcomes by Race in Breast Cancer Screening With Digital Breast Tomosynthesis Versus Digital Mammography

Purpose:

Digital breast tomosynthesis (DBT) in conjunction with digital mammography (DM) is becoming the preferred imaging modality for breast cancer screening compared with DM alone, on the basis of improved recall rates (RR) and cancer detection rates (CDRs). The aim of this study was to investigate racial differences in the utilization and performance of screening modality.

Methods:

Retrospective data from 63 US breast imaging facilities from 2015 to 2019 were reviewed. Screening outcomes were linked to cancer registries. RR, CDR per 1,000 examinations, and positive predictive value for recall (cancers/recalled patients) were compared.

Results:

A total of 385,503 women contributed 542,945 DBT and 261,359 DM screens. A lower proportion of screenings for Black women were performed using DBT plus DM (referred to as DBT) (44% for Black, 48% for other, 63% for Asian, and 61% for White). Non-White women were less likely to undergo more than one mammographic examination. RRs were lower for DBT among all women (8.74 versus 10.06, P < .05) and lower across all races and within age categories. RRs were significantly higher for women with only one mammogram. CDRs were similar or higher in women undergoing DBT compared with DM, overall (4.73 versus 4.60, adjusted P = .0005) and by age and race. Positive predictive value for recall was greater for DBT overall (5.29 versus 4.45, adjusted P < .0001) and by age, race, and screening frequency.

Conclusions:

All racial groups had improved outcomes with DBT screening, but disparities were observed in DBT utilization. These data suggest that reducing inequities in DBT utilization may improve the effectiveness of breast cancer screening.

Abstract PS7-02: The relationship of established breast cancer risk factors with breast cancer subtypes

Background: Molecular characterization of breast tumors has revealed four subtypes which differ in expression of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Breast cancer subtypes have different prognosis and unique risk factors. Breast cancer risk assessment models mainly reflect risk of ER/PR+ HER2- tumors, the most common subtype, and may not reflect risk of other subtypes. The study objective was to compare associations of established breast cancer risk factors across invasive breast cancer subtypes.

Methods: The study population included women aged 40-84 years who had a screening mammogram at Massachusetts General Hospital, Newton Wellesley Hospital, or the University of Pennsylvania from 2006-2015. Patients completed a risk factor questionnaire and additional risk factors were ascertained from clinical records. Women with prior breast cancer, breast implants, or BRCA1/2 mutations were excluded. Women diagnosed with breast cancer within 6 months were excluded to remove those with cancer at the time of risk assessment. Tumor characteristics were obtained from linkage with hospital and state cancer registries. For invasive tumors, subtype was defined based on immunohistochemistry as ER and/or PR+ HER2-, ER and/or PR+HER2+, ER and PR- HER2+, or ER and PR and HER2- (triple negative breast cancer, TNBC). Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for breast cancer using time from mammogram to cancer diagnosis or censoring. Separate Cox models were fit for each subtype, and patients who developed DCIS or another subtype, died, or were alive and cancer free on December 31, 2017 were censored. Age, biopsy history, atypical hyperplasia, age at menarche, age at first live birth, family history, race, BMI, and breast density at the time of screening were included in the models.

Results: The study population (N=197,836) had a mean age of 54 years and 74% of patients were white, 15% were Black, and 11% were other races. During a mean follow-up of 6.3 years, 4,510 (2.3%) women developed breast cancer. Of these cancers, 1068 (24%) were DCIS. Of the invasive cancers, 2675 (77%) were ER/PR+HER2-, 290 (8%) were ER/PR+HER2+, 108 (3%) were ER/PR-HER2+, 264 (8%) were TNBC and 105 (3%) had missing subtype. For ER/PR+HER2- cancers, all risk factors were consistent with the literature and statistically significant. Breast density was associated with increased risk of all four subtypes compared to women with less dense breasts. Atypical hyperplasia was strongly associated with HER2+ cancers (HR=2.97 CI 1.63-5.40 p&lt;0.01), less strongly associated with ER/PR+HER2- cancers, and not significantly associated with TNBC. Black women had higher risk of TNBC than white women (HR=2.61 CI 1.91-3.57 p&lt;0.01).

Conclusion Our results highlight both similarities and heterogeneity in risk factors across breast cancer subtypes. Prior diagnosis of atypical hyperplasia was more strongly associated with HER2+ compared to HER2- tumors. While it is well known that Black women have higher risk of TNBC, it is striking that the more than two-and-a-half-fold increased risk persisted even with comprehensive adjustment for breast cancer risk factors in a screened population. These results suggest that additional factors, such as genetics, biomarkers, and environmental exposures should be included in risk assessment to better capture risk of less common breast cancer subtypes such as TNBC.

Risk factors for breast cancer subtypes among 197,836 women undergoing screening mammography*ER/PR+ HER2- N=2674ER/PR+ HER2+ N=290ER/PR-HER2+ N=108ER/PR/HER2- N=264HR,95% CIpHR,95% CIpHR,95% CIpHR,95% CIpBlack vs. white unadjusted0.67,0.58-0.77&lt;0.010.73,0.48-1.090.120.91,0.49-1.680.772.61,1.96-3.46&lt;0.01Black vs. white multivariate*0.72,0.63-0.83&lt;0.010.75,0.49-1.150.191.23,0.65-2.330.532.61,1.91-3.57&lt;0.01Atypical Hyperplasia*1.38,1.02-1.870.042.77,1.42-5.42&lt;0.013.89,1.03-14.70.040.43,0.06-3.140.401 FDR** vs. none1.46,1.32-1.63&lt;0.011.16,0.82-1.650.391.93,1.18-3.160.011.11,0.75-1.630.602 FDR** vs. none2.12,1.67-2.71&lt;0.011.17,0.44-3.150.751.90,0.47-7.760.372.81,1.44-5.49&lt;0.01BMI ≥25 vs. &lt;25 kg/m2*1.37,1.25-1.50&lt;0.011.35,1.04-1.750.031.07,0.71-1.640.741.29,0.97-1.730.08Dense vs. non-dense breasts1.55,1.42-1.69&lt;0.011.75,1.34-2.29&lt;0.011.97,1.25-3.10&lt;0.011.65,1.26-2.17&lt;0.01*Adjusted for all factors in the table and additionally age, biopsy, age at menarche, age at first live birth**FDR= first degree relative with breast cancer

Citation Format: Anne Marie McCarthy, Tara Friebel, Wei He, Michaela Welch, Sarah Ehsan, Kevin Hughes, Alan Semine, Jinbo Chen, Despina Kontos, Susan Domchek, Emily Conant, Aditya Bardia, Constance Lehman, Katrina Armstrong. The relationship of established breast cancer risk factors with breast cancer subtypes [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-02.

Imaging Phenotypes of Breast Cancer Heterogeneity in Preoperative Breast Dynamic Contrast Enhanced Magnetic Resonance Imaging (DCE-MRI) Scans Predict 10-Year Recurrence

PURPOSE

Identifying imaging phenotypes and understanding their relationship with prognostic markers and patient outcomes can allow for a noninvasive assessment of cancer. The purpose of this study was to identify and validate intrinsic imaging phenotypes of breast cancer heterogeneity in preoperative breast dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) scans and evaluate their prognostic performance in predicting 10 years recurrence.

EXPERIMENTAL DESIGN

Pretreatment DCE-MRI scans of 95 women with primary invasive breast cancer with at least 10 years of follow-up from a clinical trial at our institution (2002-2006) were retrospectively analyzed. For each woman, a signal enhancement ratio (SER) map was generated for the entire segmented primary lesion volume from which 60 radiomic features of texture and morphology were extracted. Intrinsic phenotypes of tumor heterogeneity were identified via unsupervised hierarchical clustering of the extracted features. An independent sample of 163 women diagnosed with primary invasive breast cancer (2002-2006), publicly available via The Cancer Imaging Archive, was used to validate phenotype reproducibility.

RESULTS

Three significant phenotypes of low, medium, and high heterogeneity were identified in the discovery cohort and reproduced in the validation cohort (P < 0.01). Kaplan-Meier curves showed statistically significant differences (P < 0.05) in recurrence-free survival (RFS) across phenotypes. Radiomic phenotypes demonstrated added prognostic value (c = 0.73) predicting RFS.

CONCLUSIONS

Intrinsic imaging phenotypes of breast cancer tumor heterogeneity at primary diagnosis can predict 10-year recurrence. The independent and additional prognostic value of imaging heterogeneity phenotypes suggests that radiomic phenotypes can provide a noninvasive characterization of tumor heterogeneity to augment personalized prognosis and treatment.

HSR19-079: Disparities in Accessing Screening Mammography: Opportunities for Improving Diagnostic Outcomes

Introduction: Screening mammography is a key component of secondary prevention programs targeting reductions in breast cancer mortality. The early detection of cancers facilitates treatment at a more curable, locoregionally limited stage. We describe characteristics and outcomes of women who had only one screening mammogram versus those who had annual or biennial screens. Methods: A cloud-based big data platform is being used to integrate and transform data from electronic medical records, radiology management systems, and tumor registries to create a learning health system. This analysis includes data from 227,834 women, aged 40–79 years, who underwent screening mammograms between January 2015 and June 2018 at 64 imaging facilities within 3 large, geographically diverse healthcare organizations. Patients with breast cancer history or implants were excluded. Women were defined as having one screen if they had >24 months of follow-up with evidence of only one screen and were defined as having more than one screen if they had 2 screens at least 9 months apart. Interval cancer was defined as a breast cancer in the 12 months following a negative baseline mammogram. The chi-square test was used to test for differences between cohorts. Results: Of 227,834 women, 18.8% (n=42,911) met criteria for one screen [1-screen] and 81.2% (n=184,923) for 2 screens [2-screens]. There were significant differences between the groups in age (40.4% 60-79 years in the 1-screen cohort vs 49.1% in 2-screens; P<.001), race (24.7% African American and 5.3% Asian in the 1-screen cohort and 18.5% and 3.6% in 2-screens; P<.001), and lifetime risk of breast cancer (6.9% were in the elevated risk category in the 1-screen cohort and 9.3% in 2-screens; P<.001). Recall rate for the 1-screen cohort was 16.6% compared to 7.7% for the second screen for the 2-screens (P<.001). The interval cancer rate was significantly higher (P<.001) for the 1-screen cohort (2.9 per 1000 screens) as compared to the second screen for the 2-screens (0.8 per 1000 screens). Conclusion: Women with evidence of only one screen during the 3.5-year study period tended to be younger and non-white. Although they had lower scores for lifetime risk of breast cancer, recall rates were twofold higher and interval cancer rates were threefold higher in the 1-screen cohort. Targeted initiatives are needed to improve adherence to screening in women at risk of noncompliance.

Structure Change and Rattling Dynamics in Cu12Sb4S13 Tetrahedrite: an NMR Study

We present a ⁶³Cu and ⁶⁵Cu NMR study of Cu₁₂Sb₄S₁₃, the basis for tetrahedrite thermoelectric materials. In addition to electronic changes observed at the T_c = 88 K metal-insulator transition, we find that locally there are significant structural changes occurring as the temperature extends above T_c, which we associate with Cu atom displacements away from symmetry positions. Spin-lattice relaxation rates (1/ T₁) are dominated by a quadrupolar process indicating anharmonic vibrational dynamics both above and below T_c. We used a quasiharmonic approximation for localized anharmonic oscillators to analyze the impact of Cu rattling. The results demonstrate that Cu-atom rattling dynamics extends unimpeded in the distorted structural configuration below T_c and provide a direct measure of the anharmonic potential well.

Native defects and impurity band behavior in half-Heusler thermoelectric NbFeSb

Native defects are identified that dominate the electronic behavior and generate impurity-band states in the promising thermoelectric NbFeSb.

Abstract 2770: Racial differences in quantitative measures of area and volumetric breast density

Introduction: Breast density is a strong risk factor for breast cancer. Several studies found Black women to have lower breast density than white women on average, which may be partly due to racial differences in BMI, which is inversely associated with density. Our study utilizes fully-automated, validated quantitative measurements of both area and volumetric breast density. We assess racial differences in these novel measures, accounting for age, BMI, and other established breast cancer risk factors.

Methods: From women who underwent mammography screening at our institution in 2010-11, we analyzed all available raw digital mammograms for women who had BMI recorded in electronic medical records at the time of screening. A previously-validated, publically-available, fully-automated software algorithm developed in our institution was used to generate per-woman estimates of absolute and percent area density. Volumetric estimates of absolute and percent dense tissue were obtained using FDA-cleared software (Quantra™, Hologic, Inc). Women identified as White or Black/African American with no prior history of breast cancer were included (N = 2845). Patient characteristics and mean density measures were compared by race using Chi-square tests and t-tests. Density measures were log-transformed and z-score standardized. Linear regression was performed to assess racial differences in mean density measures, adjusted for age, BMI, and breast cancer risk factors (prior biopsy, age at menarche, menopause status, family history, age at first birth, HRT use). We also tested the interaction of race and BMI on density.

Results: The mean age of patients was 57, and was similar for white and black women (p = .159). Black women had higher mean BMI than white women (32.0 kg/m2 vs. 26.0 kg/m2, p&lt;.001). Black women had higher absolute area (40.1 vs. 33.1 cm2, p&lt;.001) and volume (187.2 vs. 181.6 cm3, p&lt;.001) density than white women, but lower area (19.6% vs. 23.5%, p&lt;.001) and volume percent density (11.6% vs. 13.4%, p&lt;.001). After adjusting for age, BMI, and breast cancer risk factors, black women had higher breast density across all measures (absolute area density β = 0.211 p&lt;0.001, area percent density β = 0.099 p = .021, absolute volume density β = 0.242 p&lt;.001, volume percent density β = 0.221 p&lt;.001). The interaction between race and BMI was significant for area percent (p = .001) and volume percent density (p&lt;.001), and near significant for volume density (p = .085). For all three measures, BMI was more strongly associated with density among white women than black women.

Conclusions: Black women had significantly higher breast density than whites using quantitative measurements which was not explained by BMI or recognized breast cancer risk factors. Furthermore, the association of BMI with density was weaker in black women than white women. Such racial differences in breast density and its association with BMI may have implications for disease risk and prevention strategies.

Citation Format: Anne Marie McCarthy, Brad Keller, Marie Synnestvedt, Emily Conant, Katrina Armstrong, Despina Kontos. Racial differences in quantitative measures of area and volumetric breast density. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2770. doi:10.1158/1538-7445.AM2015-2770

Digital breast tomosynthesis findings after surgical lipomodeling in a breast cancer survivor

Autologous fat grafting or lipomodeling is a newly-adopted technique that is gaining increasing popularity in the treatment of contour deformities following breast conservation therapy. Here, we describe the case of a 47-year-old woman with a prior history of breast cancer treated with a lumpectomy and radiation therapy. She underwent lipomodeling not only of her treated breast but also of the contralateral breast. She presented for her annual mammogram which was performed with digital breast tomosynthesis. On imaging, a space-occupying lesion of mixed density was seen, expanding the lumpectomy site. There was also subtle distortion in the contralateral, non-treated breast. This case aims to highlight the mammographic and tomosynthesis findings seen following lipomodeling that may present diagnostic challenges in this patient population.

Abstract B85: Racial differences in false-positive mammogram rates: Results from the ACRIN Digital Mammographic Imaging Screening Trial (DMIST)

Introduction: Though screening mammography reduces breast cancer mortality, it carries a significant burden of false-positives, which may lead to unnecessary procedures, anxiety, and increased costs. Because of the relatively low risk of cancer and high level of false-positives in younger women, the U.S. Preventative Services Task Force recommends against routine screening for women younger than 50. This guideline is controversial, and some have raised concerns about its application to black women, who tend to be diagnosed with breast cancer at younger ages and with more advanced disease than whites. However, few studies have quantified the burden of false-positive mammograms among black women.

Methods: The ACRIN DMIST trial compared the diagnostic accuracy of digital versus screen-film mammography among 49,528 asymptomatic women enrolled from 2001-2003 at 33 sites in the U.S. and Canada. The current study includes a subset of participants who self-identified as white (N=26,446) or black/African American (N=3176) with no prior history of breast cancer. We compared screening outcomes for white and black women based on the results of digital mammography. False-positive mammograms were defined as those with BIRADS 0, 4, or 5 designation with no subsequent cancer diagnosis in the 15-month follow-up period. Logistic regression was used to estimate the odds of false-positive mammogram by race, breast cancer risk factors, and prior films. A generalized linear mixed model was also fit to account for study site as a random effect.

Results: Black participants were slightly younger than white participants (mean 53.7 vs. 55.0). As expected, black and white women differed in terms of reproductive history, with black women having higher parity, lower age at first birth, and lower prevalence of breastfeeding. Black women were also less likely to have prior films available at mammogram interpretation than whites (86.8% vs. 91.3%). The cancer detection rate did not differ significantly by race (whites 0.95%, blacks 0.79% p=0.359). The false-positive rate was higher among blacks (9.2%) than whites (7.8%, p=0.009). Higher false-positive rates were also associated with lack of prior films, higher breast density, and being seen at a study site that enrolled a larger proportion of black participants (r=0.34, p=0.05). After adjusting for age, black women had 17% increased odds of false-positive mammograms compared to whites (OR=1.17, p=0.017). We sequentially added breast cancer risk factors (menopause status, age at menarche, age at first birth, breastfeeding, birth control use, estrogen replacement therapy, prior biopsy, family history of breast cancer), breast density, prior films, and study site to the model. Breast cancer risk factors, prior films, and study site each attenuated the coefficient for race by more than 20%. In the fully adjusted model including study site as a random effect, there was no significant difference in the odds of false-positive mammogram between black and white women (OR=1.04, p=0.561). There were no significant interactions between race and prior films, breast density, age, or menopause status with respect to false-positives.

Conclusions: Black women enrolled in the ACRIN DMIST trial had a 1.4% higher false-positive rate than whites. This higher burden of false-positives for black women is clinically significant, given the large numbers of women who undergo screening mammography in the U.S. The higher rate of false-positives among black women was explained by differences in breast cancer risk factors, lower availability of prior mammogram films, and differences in mammogram facility false-positive rates between black and white women in the ACRIN DMIST trial.

Citation Format: Anne Marie McCarthy, Jianing Yang, Mirar Bristol, Emily Conant, Katrina Armstrong. Racial differences in false-positive mammogram rates: Results from the ACRIN Digital Mammographic Imaging Screening Trial (DMIST). [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B85. doi:10.1158/1538-7755.DISP13-B85

Tradition meets innovation: transforming academic medical culture at the University of Pennsylvania's Perelman School of Medicine

Traditional performance expectations and career advancement paths for academic physicians persist despite dramatic transformations in the academic workflow, workload, and workforce over the past 20 years. Although the academic physician's triple role as clinician, researcher, and educator has been lauded as the ideal by academic health centers, current standards of excellence for promotion and tenure are based on outdated models. These models fail to reward collaboration and center around rigid career advancement plans that do little to accommodate the changing needs of individuals and organizations. The authors describe an innovative, comprehensive, multipronged initiative at the Perelman School of Medicine at the University of Pennsylvania to initiate change in the culture of academic medicine and improve academic productivity, job satisfaction, and overall quality of life for junior faculty. As a key part of this intervention, task forces from each of the 13 participating departments/divisions met five times between September 2010 and January 2011 to produce recommendations for institutional change. The authors discuss how this initiative, using principles adopted from business transformation, generated themes and techniques that can potentially guide workforce environment innovation in academic health centers across the United States. Recommendations include embracing a promotion/tenure/evaluation system that supports and rewards tailored individual academic career plans; ensuring leadership, decision-making roles, and recognition for junior faculty; deepening administrative and team supports for junior faculty; and solidifying and rewarding mentorship for junior faculty. By doing so, academic health centers can ensure the retention and commitment of faculty throughout all stages of their careers.

Abstract P4-01-08: Effect of bilateral salpingo-oophrectomy on breast MRI fibroglandular volume and background parenchymal enhancement for BRCA 1/2 mutation carriers

PURPOSE: Bilateral salpingo-oophrectomy (BSO) reduces breast cancer risk in women with BRCA1/2 mutations by approximately 50%. Annual screening for these high-risk women includes breast MRI and mammography. It is unknown whether BSO affects fibroglandular volume (FG) and background enhancement (BG) on breast MRI in this population. The purpose of this study is to assess the difference in FG and BG in BRCA1/2 mutation carriers before and after BSO on breast MRI.

METHOD AND MATERIALS: We compared FG and BG on contrast-enhanced breast MRI before and after BSO. Two readers blinded to both clinical and imaging history scored FG according to the BI-RADS criteria from 1–4: fatty, scattered, heterogeneously dense, or extremely dense. BG was graded based on the MRI BI-RADS scale from 1–4: minimal, mild, moderate, and marked. Average BIRADS scores of each reader were used to calculate mean FG and BG (±SD) before and after BSO, and compared using a paired t-test for significance.

RESULTS: We examined 60 women with BRCA1/2 mutations who underwent breast MRI before and after BSO from 2001–2011 at our institution. Five patients were excluded from the final analysis as they underwent mastectomy or bilateral radiation therapy before post-BSO MRI. Mean time to post-BSO MRI was 8.3 months ± 7 months. Mean pre- and post-operative FG were 2.64±0.78 and 2.58±0.75, respectively (p = 0.622). Mean pre- and post-operative BG were 2.46±0.93 and 1.87±0.81, respectively (p = 0.0001). Breast cancer was detected in 8 women at a median time of 3.4 years following BSO. In these 8 women, mean pre- and post-operative FG were 3.10±0.57 and 2.55±0.69, respectively. Mean pre- and post-operative BG were 3.20±0.67 and 2.35±0.71, respectively.

CONCLUSION: In this population of 55 BRCA1/2 mutation carriers who underwent breast MRI before and after BSO, there was a significant reduction in BG following BSO. There was no difference in FG on MRI following BSO. For the 8 patients in this cohort who were diagnosed with breast cancer after BSO, there was a trend toward higher FG and BG both before and after BSO, in comparison to the patients who were not diagnosed with breast cancer, suggesting that rates of higher FG and BG may be associated with increased risk for developing breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-01-08.

Disparities in screening mammography services by race/ethnicity and health insurance

BACKGROUND

Black and Hispanic women are diagnosed at a later stage of breast cancer than white women. Differential access to specialists, diffusion of technology, and affiliation with an academic medical center may be related to this stage disparity.

METHODS

We analyzed data from a mammography facility survey for the metropolitan region of Chicago, Illinois, to assess in part whether quality breast imaging services were equally accessed by non-Hispanic white, non-Hispanic black, and Hispanic women and by women with and without private insurance. Of 49 screening facilities within the city of Chicago, 43 facilities completed the survey, and 40 facilities representing about 149,000 mammograms, including all major academic facilities, provided data on patient race/ethnicity.

RESULTS

Among women receiving mammograms at the facilities we studied, white women were more likely than black or Hispanic women to have mammograms at academic facilities, at facilities that relied exclusively on breast imaging specialists to read mammograms, and at facilities where digital mammography was available (p<0.001). Women with private insurance were similarly more likely than women without private insurance to have mammograms at facilities with these characteristics (p<0.001).

CONCLUSIONS

Black and Hispanic women and women without private insurance are more likely than white women and women with private insurance to obtain mammography screening at facilities with less favorable characteristics. A disparity in use of high-quality mammography may be contributing to disparities in breast cancer mortality.

Morphologic blooming in breast MRI as a characterization of margin for discriminating benign from malignant lesions

RATIONALE AND OBJECTIVES

Develop a fully automated, objective method for evaluating morphology on breast magnetic resonance (MR) images and evaluate effectiveness of the new morphologic method for detecting breast cancers.

MATERIALS AND METHODS

We present a new automated method (morphologic blooming) for identifying and classifying breast lesions on MR that measures margin sharpness, a characteristic related to blooming, defined as rapid enhancement, with a border that is initially sharp but becomes unsharp after 7 minutes. Independent training sets (98 biopsy-proven lesions) and testing sets (179 breasts, 127 patients, acquired at five institutions) were used. Morphologic blooming was evaluated as a stand-alone feature and as an adjunct to kinetics using free-response receiver operating characteristic and sensitivity analysis. Dependence of false-positive (FP) rates on acquisition times and pathologies of contralateral breasts were evaluated.

RESULTS

Sensitivity of morphologic blooming was 80% with 2.46 FP per noncancerous breast: FPs did not vary significantly by acquisition times. FPs varied significantly by pathologies of contralateral breasts (cancerous contralateral: 4.29 FP/breast; noncancerous contralateral: 0.48 FP/breast; P < .0001). Evaluation of 45 cancers showed suspicious morphologies on 10/15 (67%) cancers with benign-like kinetics and suspicious kinetics on 5/10 (50%) cancers with benign-like morphologies.

CONCLUSION

We present a new, fully automated method of identifying and classifying margin sharpness of breast lesions on MR that can be used to direct radiologists' attention to lesions with suspicious morphologies. Morphologic blooming may have important utility for assisting radiologists in identifying cancers with benign-like kinetics and discriminating normal tissues that exhibit cancer-like enhancement curves and for improving the performance of computer-aided detection systems.

FDG PET positive lymph nodes are highly predictive of metastasis in breast cancer

AIM

To determine whether or not fluorodeoxyglucose positron emission tomography (FDG PET) imaging when positive could obviate the necessity for sentinel lymph node biopsy and for complete axillary node dissection in patients with breast cancer.

METHODS

A total of 80 female patients with a histological diagnosis of breast cancer and clinically negative axillary nodes underwent an FDG PET and sentinel lymph node biopsy (SLNB) or total axillary dissection for staging of axilla. Both SLNB and axillary dissection were performed in 72 patients, while eight patients had total axillary dissection without SLN biopsy.

RESULTS

Of the 80 patients, 36 had lymph node metastasis on histopathology. SLNB was positive for metastasis in 35 (97%) of 36 patients (29 macrometastasis and seven micrometastasis). In the patient with false negative SLNB, the lymph node was completely replaced by the tumour. The FDG PET was true positive in 16 of 36 patients (sensitivity, 44%). There were two false positive studies with FDG PET, resulting in a specificity of 95%. The positive predictive value and accuracy of FDG PET for the detection of axillary lymph node metastasis were 89% and 72%, respectively. Univariate analysis revealed that higher grade of tumour, increased size and number of axillary lymph nodes were significantly associated with positive FDG PET results for axillary staging.

CONCLUSION

FDG PET cannot replace histological staging using SLNB in patients with breast cancer. However, FDG PET has a high specificity and positive predictive value for staging of the axilla in these patients. The patients with higher grade of tumour, larger size and higher number of axillary lymph nodes may be considered for FDG PET scan for axillary staging.

Radiologists' preferences for digital mammographic display. The International Digital Mammography Development Group

PURPOSE

To determine the preferences of radiologists among eight different image processing algorithms applied to digital mammograms obtained for screening and diagnostic imaging tasks.

MATERIALS AND METHODS

Twenty-eight images representing histologically proved masses or calcifications were obtained by using three clinically available digital mammographic units. Images were processed and printed on film by using manual intensity windowing, histogram-based intensity windowing, mixture model intensity windowing, peripheral equalization, multiscale image contrast amplification (MUSICA), contrast-limited adaptive histogram equalization, Trex processing, and unsharp masking. Twelve radiologists compared the processed digital images with screen-film mammograms obtained in the same patient for breast cancer screening and breast lesion diagnosis.

RESULTS

For the screening task, screen-film mammograms were preferred to all digital presentations, but the acceptability of images processed with Trex and MUSICA algorithms were not significantly different. All printed digital images were preferred to screen-film radiographs in the diagnosis of masses; mammograms processed with unsharp masking were significantly preferred. For the diagnosis of calcifications, no processed digital mammogram was preferred to screen-film mammograms.

CONCLUSION

When digital mammograms were preferred to screen-film mammograms, radiologists selected different digital processing algorithms for each of three mammographic reading tasks and for different lesion types. Soft-copy display will eventually allow radiologists to select among these options more easily.

Accuracy of sentinel lymph node biopsy in patients with large primary breast tumors

BACKGROUND

Patients with large breast tumors are increasingly undergoing neoadjuvant treatment to downstage local disease; however, accurate staging of the axilla before the initiation of chemotherapy remains problematic. In the current study, the authors report on the accuracy of sentinel lymph node (SLN) biopsy in such patients to determine the feasibility of applying this technique before induction chemotherapy.

METHODS

One hundred three patients with 104 tumors classified as American Joint Committee on Cancer (AJCC) T2 (tumor >/= 2 cm but </= 5 cm) or larger were recruited at the University of Pennsylvania and the Mayo Clinic. In the majority of cases, combined blue dye and radiotracer was used for SLN identification. After SLN identification, a completion axillary lymph node dissection was performed in 87 cases. The SLN was evaluated with hematoxylin and eosin and immunohistochemistry.

RESULTS

The SLN was identified in 99% of cases. The overall rate of lymph node metastasis was 59% (95% exact confidence interval [95% CI], 49-68%) (61 of 104 cases). The SLN false-negative rate was 2% (95% exact CI, < 1-11.5%) (2 patients). In 56 tumors >/= 3 cm, 1 false-negative result (2% [95% exact CI, < 1-15%]) was identified, and the rate of lymph node metastasis was 62.5% (95% exact CI, 48. 5-75%) (35 of 56 tumors). Within 30 SLN positive patients with tumors >/= 3 cm and complete axillary lymph node dissection, 3 of 8 patients (37.5% [95% exact CI, 8.5-75.5%]) with micrometastasis (</= 2 mm) to the SLN had positive non-SLN compared with 21 of 22 patients (95.5% [95% exact CI, 77-100%]) with macrometastasis (> 2 mm) to the SLN (P = 0.002).

CONCLUSIONS

SLN biopsy for patients with large breast tumors is technically feasible and highly accurate. SLN biopsy should be considered for the staging of clinically negative axilla in patients scheduled to receive neoadjuvant chemotherapy.

Optical imaging as an adjunct to sonograph in differentiating benign from malignant breast lesions

The role of near infrared (NIR) diffusive light imaging as an adjunct to ultrasound in differentiating benign from malignant lesions was evaluated in 27 mammography patients with infiltrating ductal carcinomas, apocrine metaplasia, fibroadenomas, radial scar and ductal hyperplasia, cysts, and normal tissues. Conventional ultrasound/mammography images were graded based on BI-RADS assessment categories. The spatial NIR measurements were made at wavelengths of 750 and 830 nm. Functional images, such as relative changes of deoxyhemoglobin (deoxyHb) and total blood concentration, were estimated from the dual wavelength measurements. Maximum relative deoxyHb and blood concentration changes were measured, and spatial correlation of masses in relative deoxyHb and blood concentration images for each breast were calculated. For the five biopsy proven benign lesions, ultrasound/mammography diagnoses were suspicious for malignancy (four cases) and highly suspicious for malignancy (one case). Four lesions showed less than 1.0 V maximum deoxyHb and less than 1.5 V maximum blood concentration levels on average and spatial image correlation showed no correlated masses in both deoxyHb and blood concentration images. For the four biopsy proven malignant lesions, ultrasound/mammography diagnoses were highly suspicious for malignancy. Maximum deoxyHb and blood concentration changes were greater than 2.9 V on average except one lesion which showed smaller deoxyHb signal (maximum 0.85 V) but the deoxyHb mass and blood concentration mass were highly correlated.

Sarcoidosis in systemic sclerosis: report of 7 cases

OBJECTIVE

To describe the clinical, radiologic, and pathologic features of coexistent systemic sclerosis (SSc) and sarcoidosis, 2 conditions of unknown cause associated with altered cellular immune response.

METHODS

We reviewed clinical information, results from laboratory and radiologic studies, and lung or lymph node biopsy samples of 7 patients with concurrent SSc and sarcoidosis evaluated at 2 academic referral centers between 1989 and 1993.

RESULTS

Each patient fulfilled American College of Rheumatology criteria for the classification of SSc. SSc and sarcoidosis developed simultaneously in 4 patients, whereas in 3 others sarcoidosis was diagnosed more than 6 years after the onset of SSc. The onset of sarcoidosis was characterized by fever, weight loss, or increasing respiratory symptoms. Each patient had radiographic evidence of intrathoracic lymphadenopathy and/or interstitial lung disease. Examination of lung or lymph node biopsies demonstrated noncaseating granulomas. Treatment with corticosteroids was associated with improved lung function.

CONCLUSION

Since sarcoidosis coexists with SSc more frequently than previously suggested, it should be considered in patients with SSc presenting with new pulmonary symptoms. Recognizing sarcoidosis in patients with SSc is important, since these patients may benefit from corticosteroid therapy.